Employee voice has become increasingly important throughout the NHS and particularly for Nottinghamshire Healthcare NHS Trust (NHT). The trust’s recently appointed chief executive has tackled many key challenges, including a ‘requires improvement’ Care Quality Commission (CQC) rating, high levels of turnover, and low staff satisfaction scores. Employee voice was seen as a key mechanism to improve these issues, and changes include new board membership, the ‘Freedom to Speak Up Guardian’, the ‘Just Culture’ approach, and employee voice being a standing item of the trust’s board agenda. Focusing on employee voice is a way to encourage employees to speak up about issues they face, to improve patient safety, and ultimately to enhance both patient and employee experiences.

While this case study reflects an increased focus on employee voice, and the desire to empower staff throughout the organisation, it also highlights that transformation of a large and complex organisation takes time and requires buy-in throughout the organisation.


  • poor CQC rating
  • high turnover
  • large, complex organisation


  • ‘Just Culture’
  • ‘Freedom to Speak Up Guardian’
  • employee voice on board’s agenda


NHT is a provider of mental health, intellectual disability and community healthcare services for Nottinghamshire, annually attending to around 190,000 patients. The 9,000 staff carry out a wide range of roles, providing integrated and co-ordinated care and support across 150 sites with a budget for 2019/20 of £465 million. They run services ranging from a high-security psychiatric hospital, to healthcare in prisons, through to community care.


Complex organisation

One of the most notable features of NHT is the complexity, scale and range of the services they provide. NHT is spread across multiple locations from hospitals and prisons to community settings, and has a diverse workforce, including highly educated consultants through to entry-level jobs. Furthermore, they work with some of the most vulnerable people in society, often dealing with life-and-death situations, regularly in the public eye, where human error is highly scrutinised and widely reported in the media. This creates a complex and challenging work environment with high demands on employees.

This complexity is exacerbated by continual change, restructuring, individual-level services being recommissioned or decommissioned, mergers, and changes in funding, to name a few. Such changes are a regular feature of most NHS trusts; in particular, NHT faces three key challenges:

  • CQC rating (2019) of ‘requires improvement’ in three of the main five categories (safe, responsive and well-led). It was stated that ‘there was a disconnect between operational staff and the board in the communication of messages and a lack of consultation and engagement’ (CQC report).
  • Staff recruitment and retention: NHT has a vacancy rate of 11% and 14% for registered nurses (CQC report) compared with a national average of 8.5% (ONS) and 12% for registered nurses (Nursing Times), particularly due to cuts in bursaries.
  • Poor staff survey results when benchmarked against other trusts.

Hierarchy and lack of trust

NHT, like other NHS trusts, is also a complex, highly regulated organisation, with over 800 policies, procedures and guidelines. This high level of regulation demonstrates the complexity of the work and the organisational culture that underpins it. Employees felt this hierarchy and regulation, although necessary, can stifle individual decisions, and creates problems for employee voice:

  • Communicating decisions from ‘board to ward’: Decision-making is problematic given the bureaucratic nature of this process and the levels through which decisions go before reaching an outcome. For example, messages were misinterpreted and inadvertently changed at each of these levels, meaning messages were distorted or sometimes received correctly, but the original intentions were skewed.
  • Hierarchical focus: prioritising staff grades over experience and expertise: There were examples where employees who had years of experience and high-level nursing qualifications were dismissed because their current role was a lower grade than colleagues. This suggests that official staff grades take precedence over experience and expert knowledge.
  • Confusion and absence of direct line management: Line managers are an important channel for voice, 1 however some employees stated that there was confusion over reporting structures and direct reports. As a result of both the organisational focus on grades and this uncertainty over who they reported to, staff were often reluctant, or in some cases unable, to raise ideas or concerns with their line manager.

Culture and lack of autonomy

The organisation’s previous target-driven culture had led to employees feeling deprofessionalised and not trusted to make key decisions or given the autonomy to do their jobs effectively: ‘There’s lots of narrative identifying, describing what the problem is, but there’s a lack of “so what”… I don’t think [we’re] giving staff permission to give things a try.’

Employees also felt that blame culture had pervaded the trust, and the NHS more broadly: ‘So the feedback from our clinic from our doctors I would say specifically is that if they were to make a mistake or misjudgement or something like that, they expect to be blamed for it.’ Some argued that to create a genuinely safe environment for staff and service users, staff had to be free to take risks and make difficult decisions. Additionally, the trust previously undertook time and motion studies, 2 which were said to restrict the autonomy and professionalism of staff.

Tackling the challenges to improve employee voice

NHT is undergoing many key changes, some introduced through the trust’s new leadership and others as a result of a wider focus on employee voice across the NHS as a whole. Employee voice was felt to be particularly important for an organisation like the NHS, to help leaders improve decision-making by drawing on a wider range of perspectives:

Employee voice can help senior leaders, decision-makers and influencers take better-informed decisions when they’re thinking about what they do in a large, busy, complex organisation, and… really be able to tap into people[’s knowledge], who we don’t necessarily hear from… [it creates a] different and thriving culture if you have an organisation where people genuinely feel able to speak up and be heard, and in a position to influence change.


One of the significant changes the trust has made is appointing a new CEO with a clinical background and a focus on employee voice. This new leadership is shifting the trust’s culture away from targets and figures towards focusing on the employee experience, particularly front-line staff. This shift in leadership is part of a larger focus on making the trust a ‘great place to work’, seeking to give employees more control, and focusing on wellbeing. However, interviewees acknowledged that in a large, bureaucratic and complex organisation, with over 9,000 staff, spread over diverse sites and roles, such changes would take a significant length of time to be felt on the ground: ‘We know that staff voice has a latent impact on patients. So if staff feel like they’re not being heard, and they’re not being engaged, then you know that there’s a latent patient experience and element to that.’

Developing new channels for employee voice

  • Improving surveys: Engaging employees in voice mechanisms, in particular employee surveys, can be a challenge for the trust. They have a range of surveys, many of which are compulsory, which produce great data but leave employees experiencing survey fatigue. 3 This is exacerbated when they feel little or no action has been taken on previous surveys. To improve this experience, the trust is exploring how to show they are listening to the feedback, and using sentiment analysis6 to gain a deeper understanding of people’s views and take action.
  • Employee voice on board’s agenda: Employee voice is a standing agenda in NHT’s monthly board meetings. This mirrors the focus on patient voice, which has been a longstanding agenda item. The board focuses on one division per month, giving employees in that division the opportunity to directly feed back to the board. However, uptake on this is low, with only 15–20% of staff generally responding. Employees suggested this was because of high workload and staff feeling little action would be taken from their feedback. A key challenge was keeping staff engaged while changes are being decided upon and implemented, as this process can be slow for a large organisation such as NHT.

Individual voice – focusing on wellbeing

There is a new focus within the trust on the health and wellbeing of staff, particularly in reducing stress and burnout. Staff absence is estimated to cost the trust about £20 million per annum and impacts on patient outcomes and care as well as staff wellbeing. One interviewee pointed to a report that provides evidence that a focus on staff health and wellbeing ultimately means that staff are better able to care for patients. It was felt that employee voice was important for employee health and wellbeing, specifically that employees are able to voice their needs rather than applying a one-size-fits-all policy.

Moving away from hierarchy: empowering staff at all levels

The senior leaders described improving employee voice by co-producing and cosolving problems: ‘I think that the organisation has been top-down… a lot of the problems that we’ve got in terms of our staff experience are because [employee] voice hasn’t actually been heard.’ NHT is seeking to put employees first and a key approach to this was through Just Culture. This seeks to move from blame and hierarchy towards a learning culture, where understanding and learning from mistakes are central.

Just Culture seeks to empower staff at any grade to speak out, which is particularly important in the NHS where employees’ grades are seen as important. For example, some of the training materials for Just Culture specifically focus on these power differentials, depicting hypothetical situations where less experienced staff challenge senior team members over breakdowns in communication, breaches of safety protocol, and systematic issues. Training examples highlight that ‘speaking up’ is the responsibility of all members of staff, regardless of their experience or grade.

Freedom to Speak Up Guardians

Freedom to Speak Up Guardians5 are part of an NHS-wide approach to improving employee voice. The role supports employees and provides them with opportunities to explore issues that they are facing and represent these views to others. The Francis Review, which came from the failings at Mid Staffordshire NHS Foundation Trust, highlighted that nationally only 72% of respondents felt it was safe to raise a concern.

NHS reports on speaking up closely connect it with whistleblowing. Some literature and training material in this area uses the two terms interchangeably. While there is a clear connection between speaking up and whistleblowing, an interview with a Freedom to Speak Up Guardian highlighted that speaking up is about much more than this: ‘It should be about being listened to and heard and embraced by everybody in the organisation. I’m not sure we’ve got that right.’

While the Freedom to Speak Up Guardian offers an interesting avenue to support employee voice, employees felt the trust should work towards having a culture where everyone has the psychological safety to speak up. There was a recognition here that these changes wouldn’t happen overnight and that the process of making speaking up a normalised part of working lives would take time to implement throughout the trust.


1 For more discussion see: Shipton, H., King, D., Pautz, N. and Baczor, L. (2019) Talking about voice: employees’ experiences. London: Chartered Institute of Personnel and Development.

2 Time and motion studies are a scientific management technique that involves measuring how long tasks take and redesigning work to maximise efficiency (King, D. and Lawley, S. (2019) Organizational Behaviour. Oxford: Oxford University Press). By setting how long a task should take, and the mechanisms to complete it, tasks are routinised and individual autonomy is reduced.

3 Survey fatigue occurs when respondents feel tired or uninterested in completing a survey. It often occurs when there are too many surveys or they do not see that the survey results in action.

4 Sentiment analysis is a form of machine learning that detects opinions and automatically analyses responses. It is useful to analyse large quantities of data, which would be highly time-consuming to analyse manually.

5 The Freedom to Speak Up report came about as a result of the Francis Enquiry (2010) into failings of care in the Mid Staffordshire NHS Foundation Trust. NHS staff were asked to share their experiences of speaking up and interviews were conducted with a sample of those who came forward. The report sets out a clear pathway for how the NHS should deal, at all levels, with concerns raised by staff. This pathway includes guidance on identifying when things are wrong, how individuals should raise concerns, how these concerns should be treated, how outcomes should be fed back, and how to reflect and move forward from this process.

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